Reflect and share your own personal thoughts regarding the morals and ethical dilemmas you may face in the health care field.

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Reflect and share your own personal thoughts regarding the morals and ethical dilemmas you may face in the health care field.

My Nursing Ethics

After reading the Topic 1 materials, complete the questionnaire titled, “My Nursing Ethic.”

Using the reading and the questionnaire, swrite a paper of 750-1,000 words in which you describe your professional moral compass. A you write your paper, include the following:

What personal, cultural, and spiritual values contribute to your worldview and philosophy of nursing? How do these values shape or influence your nursing practice?
Define values, morals, and ethics in the context of your obligation to nursing practice. Explain how your personal values, philosophy, and worldview may conflict with your obligation to practice, creating an ethical dilemma.
Reflect and share your own personal thoughts regarding the morals and ethical dilemmas you may face in the health care field. How do your personal views affect your behavior and your decision making?
Do not be concerned with the use of ethical terminology for this paper.

Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

1. Visit the NetMotion Web site (www.netmotionwireless.com) and access and read other Mobility XE success stories. Discuss the patterns that can be observed in the benefits that Mobility XE users have realized via its deployment and use.

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1. Visit the NetMotion Web site (www.netmotionwireless.com) and access
and read other Mobility XE success stories. Discuss the patterns that
can be observed in the benefits that Mobility XE users have realized via
its deployment and use.

2. Do some Internet research on the security implications of HIPPA
requirements for hospital networks. Discuss the major types of
security mechanisms that must be in place to ensure hospital
compliance with HIPPA requirements.
3. Do some Internet research on the use of VLANs in hospitals.
Summarize the benefits of using VLANs in hospitals and identify
examples of how St. Luke’s could further enhance its wireless network
by implementing VLANs.

What technology does your facility use?

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What technology does your facility use?

Discussion Question 2 Using the South University Online Library or the Internet, research about nursing informatics or technologies used in nursing. Based on your research, answer the following questions:
Discussion Question 2
Using the South University Online Library or the Internet, research about nursing informatics or technologies used in nursing. Based on your research, answer the following questions:
• What technology does your facility use?
• How has it improved patient care or outcomes?
• What can be done to make it more useful or to further improve patient care or outcomes?
Citations should conform to APA guidelines. You may use this APA Citation Helper as a convenient reference for properly citing resources or connect to the APA Style website through the APA icon below.

Brocas Aphasia and Treatment Options for Word Finding Difficulties

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A common condition that is an acquired language/communication disorder is known to be Aphasia. This disorder is usually caused from head trauma, brain tumors, stroke, or other neurogenic conditions in which it impairs a person’s speech and language. More adults than children are affected by this devastating disorder. Stroke is known as the number one leading cause of aphasia. Statistics show that over 1 million Americans struggle with the life-changing condition. An incline is expected as population ages in addition to what is now over 200,000 new cases each year. Broca’s aphasia is the most common type of nonfluent aphasia. An individual with non-fluent aphasia suffers with grasping the meaning of spoken words but without severe impairment of connected speech. The frontal lobe of the brain is the primary affected area which leads to several other symptoms. The affected area of the brain is specifically responsible for motor movements. Therefore, trauma to the frontal lobe leads one to experience right-side paralysis of the limbs.

It is important for individuals to keep in mind that aphasia does not impair intelligence in any way. The language disorder specifically presents difficulty to understand, speak, read, or write. The human brain is divided into two equal halves, right hemisphere and the left hemisphere. Depending on where the damage is located on the patient determines the affected area. Impaired speech and language is anatomically different. The utmost impairment results in the language centers located in the left hemisphere. However, “Aphasia can also occur as a result of damaging to the right hemisphere; that is often referred to as crossed aphasia, to denote that the right hemisphere is language dominant in these individuals” (American Speech-Language- Hearing Association, 2018).  Due to this trauma it is likely that patients with Broca’s aphasia and frontal lobe lesions struggle more with verb naming.

The two main causes of aphasia are stroke and traumatic brain injury. A stroke can occur either as an ischemic stroke or as a hemorrhagic stroke. Blockage that disrupts blood flow to a region of the brain is an ischemic stroke. A hemorrhagic stroke occurs when a ruptured blood vessel damages surrounding tissue in the brain. “According to the National Aphasia Association (n.d.), about 25%-40% of stroke survivors experience aphasia” (ASHA, 2018). Severity of the trauma to the brain depends on if aphasia could be transient or more permanent due to the traumatic brain injury. Frequently, traumatic brain injuries are accompanied by other cognitive challenges due to the involvement of multiple areas of the brain. Aphasic individuals can acquire this condition as simply from a quick concussion or from a hard fall.

There are four main types of aphasias: expressive aphasia, receptive aphasia, anomic aphasia, and global aphasia. Each specific aphasia contributes to a variety of characteristics in which one type can be identified. An individual with Broca’s (expressive) aphasia can comprehend what is being said, but unable to speak fluently due to the function of the brain. They deal with poor or absent grammar, poor syntax, omitting of words, verb or noun usage, word retrieval, phonemic errors called ‘phonemic paraphasias’, and difficulty articulating sound and words. Broca’s aphasia is considered ‘nonfluent’ because it affects the speech production (Healthline 2017). This type of expressive aphasia is the most important of the less severe forms of aphasias. Important skills that are needed through language that are affected with this disorder are attention and memory. These neurobehavioral characteristics are both poor when having Broca’s aphasia. One should note that language skills is caused from damage on the right side of the brain, while lack of memory of attention is caused from damage to the right side. This makes it more challenging for the individuals to develop sentences and process their oral output.

While some people recover from the acquired disorder, others need speech and language treatment. Providing the appropriate treatment to aphasic individuals is crucial after a stroke or other underlying causes of aphasia. While it is critical to provide intensive therapy, it is more imperative to provide a higher number of sessions. The effective amount of therapy significantly improves the individual’s production of speech, comprehension, and functional communication. Word retrieving is one of the most prominent symptoms that individuals have difficulty with and seek treatment for. Kang, Kim, Sohn, Cohen, & Paik, (2011) stated, “It has been reported that conventional word-retrieval training effectively induces partial clinical improvements, but that it rarely leads to complete functional recovery.”  The appropriate strategies must be enforced for adequate effectives of word-retrieval protocols. Generally, through literature, therapist focus on single-word noun retrieval and picture naming during treatment. Speech-language pathologist provide the appropriate strategies to provide great progress.

Semantic Feature Analysis (SFA) is a treatment used with individuals with aphasia who struggling with word retrieval problems. This therapeutic technique is used during treatment to work on naming deficits occurring with aphasia. SFA is known to improve naming of targeted items with generalization in order to dictate the stimuli. Another advantage of using this treatment is the educational aspect that individual retrieves from it for accessing semantic networks and self-cueing.  The treatment requires the individuals to retrieve features related to trained objects.

An article conducted by Magesh & Patil. (2013) consisted of four participants with aphasia, one female and three males. They were all right-handed, English speaking, and had high school educations. Each participant experienced a single episode of CVA. Treatment was twice per day two to three times per week. With the therapist controlling the session, the subject’s goal was to attempt producing words semantically associated with each target word given. The hypothesis of the study was that an efficient amount of practice would lead the subjects to minimize use of compensatory strategies. The subjects greatly benefited from the treatmen. Theresults of C-SFA (Semantic Feature Analysis) included improved production of nouns, generalization to noun from semantic categories both being untreated, four week duration of improvement after treatment ended. The study concluded participants with Broca’s aphasia improved in formativeness of discourse (Magesh & Patil, 2013).

Patients with word-retrieval benefit from another known treatment named Cathodal Transcranial DC Stimulation (ctDCS). This treatment is suggested to improve picture naming in aphasic patients. This technique eliminates volatility of cortical sites that are stimulated. The double blind, crossover study included ten right-handed patients with post-stroke aphasia. The applied intervention consisted of a week’s long randomized crossover manner allowing no less than one week difference between interventions. The focus of the treatment was to exercise the healthy side of the Broca’s homologue area on the right side with a supraorbital anodal location on the left side. Progression of picture naming task was expected from the post-stroke aphasic patients. The study concluded the positive affect of the word-retrieval treatment on the selected subjects. Cathodal transcranial DC stimulation did not propose any adverse effects per the article (Kang, Kim, Sohn, Cohen, & Paik2011).

Verb Network Strengthening Treatment (VNeST) is given to those with moderate- to- severe aphasia. Edmonds, & Babb (2011) conducted a study that include two participants recruited from the University of Florida Speech and Hearing Clinic. The individuals were diagnosed with aphasia, right-handed prior to stroke, and English speaking. They were examined using a multiple-baseline approach which covered four phases: baseline, treatment of trained items with administration of generalization and control probes, posttreatment probes, and maintenance. The designed protocol generated thematic roles related to the very network that represented relevant event schemas, influencing semantic knowledge that would activate world level forms. Sentence production for pictures and untrained semantically related verbs were the required task for the experimental design. Amongst the two participant in the multiple- baseline approach, both showed progress on the functional communication measure. One participant presented improvement on all generalization measures, while the other subject displayed limited generalization. The study concluded the participants rather did not show equal improvement with other observed participants with more moderate aphasia. The study proposed that Verb Network Strengthening Treatment for Aphasia is more appropriate for those who acquire moderate- to –severe aphasia (Edmonds, & Babb, 2011).

Evidence-based word retrieval treatment is the Cueing Hierarchy Treatment that places cues accordingly from least helpful to the most helpful. It systematically consist of a variety of cues in which aphasic individuals seek their words.  Confrontation naming task consist of the therapist presenting the clinician with a picture or an object in representation of the target word. As expected, the client struggles with word retrieval independtly. A study was conducted to determine the effectiveness on syntactic cueing therapy on picture naming and connected speech with aphasic individuals. The study consisted of six individuals with aphasia all who presented with word-finding difficulties. Part of the assessment consisted of using 80 pictures of everyday items that they viewed on a computer screen. Only one word answers were accepted while being recorded. The experiment lasted for six sessions, each involving various components. They concluded that therapy for word-finding impairments needs to facilitate word form with the production of relevant syntactic structures. Through the production of the study researchers established the effectiveness for therapy can enhance word-finding in picture naming and connected speech (Herbert, Webster, & Dyson 2012).

Two treatments were given in the same study to compare the effects for aphasic word retrieval. The purpose of the study was to expect that the use of gestural facilitation of naming (GES) would have an increasing effect of treatment compared to errorless naming treatment (ENT) alone. “Lexical-semantic system impairment will lead to difficulty in both spoken naming and auditory comprehension of words, as well as recognition and production of gestures” (Raymer, McHose, Smith, Iman, Ambrose, & Casselton, 2012).  Eight subjects with stroke-induced aphasia and problems with word retrieval were used for the single participant crossover treatment design. The method of the study required evaluation of the two treatments for a daily picture naming/ gesture production probe measure. Additionally, Standardized aphasia test and communication rating scales were administered throughout the experiment (Raymer et. al., (2012).

Errorless naming approaches treatment consisted of the individual viewing a target picture along with the name of the picture. The participant was given a variety of opportunities to rehearse the correct name of the picture by oral reading and repetition. Errors were to be avoided during the training. Therapist considered this semantic-phonological treatment approach given the semantic mechanism and name repetition that builds up to phonological skills. This approach to treatment has been very effective to those who have aphasia. Studies advised that gesture is useful for activation of lexical retrieval between the relation of action and language (Raymer et. al., 2012).

An alternative treatment used in the studied was gestural facilitation of naming. This approached used gesture abililties in order to facilitate the impaired language system. The method consisted of being based off parallel errorless naming treatment but with a gestural component added. Using imitation, manipulation, and modelling, by the clinician the participant acquired word-retrieval skills through the treatment (Raymer et. al., 2012).

Both treatments presented improvements of naming of target words in individuals with semantic and phonological impairments. The treatments did not indicate a discrepancy between each treatment. Studies show satisfaction amongst both treatments to promote word retrieval and verbal production skills in those with aphasia. The participants showed substantial progress throughout various language measures to support the satisfactory of the treatments.  “Placing persons in an enriched communication environment, whether itis through the use of errorless naming gestural facilitation, semantic-phonological activities, or orthographic cues, enhances activation of the lexical system and increases the likelihood of future word retrieval success” (Raymer et. al., 2012).

In conclusion, the devastating acquired disorder that leaves individuals with many questions has various treatments for them to reference to. Although only a few treatments were mentioned, it is safe to say that many studies have been conducted in order to provide aphasic patience’s with the proper interventions to help them live a better life. The treatments, etiologies, neurobehavioral characteristics for word finding in individuals with Broca’s aphasia were discussed. All studies represented the effectiveness of treatment options to generalize the word finding for our Broca’s patients. Some treatments will be more beneficial than others depending on the individual.



References

  • American Speeh-Language- Hearing Association (2018). Aphasia. Retrived from

    https://www.asha.org/public/speech/disorders/aphasia/
  • Code, C., & Petheram, B. (2011). Delivering for aphasia.

    International Journal of Speech-Language Pathology

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    13

    (1), 3-10.
  • Edmonds, L. A., & Babb, M. (2011). Effect of verb network strengthening treatment in moderate-to-severe aphasia.

    American Journal of Speech-Language Pathology

    ,

    20

    (2), 131-145.
  • Healthline. (2017). Broca’s Aphasia. Retrieved from

    https://www.healthline.com/health/brocas-   aphasia
  • Herbert, R., Webster, D., & Dyson, L. (2012). Effects of syntactic cueing therapy on picture naming and connected speech in acquired aphasia.

    Neuropsychological Rehabilitation

    , (4), 609.
  • Kang, E. K., Kim, Y. K., Sohn, H. M., Cohen, L. G., & Paik, N. J. (2011). Improved picture naming in aphasia patients treated with cathodal tDCS to inhibit the right Broca’s homologue area.

    Restorative neurology and neuroscience

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    (3), 141-52.
  • Macoir, J., Leroy, M., Routhier, S., Auclair-Ouellet, N., Houde, M., & Laforce, R., Jr. (n.d.). Improving verb anomia in the semantic variant of primary progressive aphasia: the effectiveness of a semantic-phonological cueing treatment.

    NEUROCASE

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    (4), 448–456. https://doi-org.ezproxylocal.library.nova.edu/10.1080/13554794.2014.917683
  • Magesh, R. co., & Patil, G. S.(2013). Efficacy of Semantic Feature Analysis as a Treatment for Word Retrieval Deficits in Individuals with Broca’s Aphasia.

    Journal of the All India Institute of Speech & Hearing

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    32

    , 114–121.
  • Medscape. (2016). Aphasia Clinical Presentation. Retrieved from

    https://emedicine.medscape.com/article/1135944-clinical
  • Raymer, A. M., McHose, B., Smith, K. G., Iman, L., Ambrose, A., & Casselton, C. (2012). Contrasting effects of errorless naming treatment and gestural facilitation for word retrieval in aphasia.

    Neuropsychological Rehabilitation

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    (2), 235–266. https://doi-org.ezproxylocal.library.nova.edu/10.1080/09602011.2011.618306
  • Rohde, A., Worrall, L., Godecke, E., O’Halloran, R., Farrell, A., & Massey, M. (2018). Diagnosis of aphasia in stroke populations: A systematic review of language tests.

    PloS one

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    (3), e0194143. doi:10.1371/journal.pone.0194143

Eadership and management are separate functions

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Eadership and management are separate functions

Eadership and management are separate functions,

Eadership and management are separate functions, but not necessary incomparable functions. The roles are interchangeable for both exceptional leaders and good mangers. The difference is the set of skills required to accomplish each positions primary goal. Managers get things done and are usually more in line with organizational power and not necessarily respected by the group as a leader.

Leaders may or may not posses the skills of a manger, but they all have the respect of the group that they are leading. Example; I worked for a lady that owned a string of nursing homes and she hired her son a the director. He was a good manger, but he never commanded the respect of the employees and residences as the leader. One of the methods that is informal,

but tells the tale of who is the leader in an organization is the grape vine. Employees speak openly and freely at the break room and they identify the leader or the person that they view as the leader. I believe that exceptional leaders must have some managerial skills, such as organization and communication and good mangers have some leadership skills such as organization and communication. The tie breaker is the respect of the group and vision.

Managers live for the present and leaders have a vision for the future. To be effective as a leader, it is necessary to influence people to carry out requests, support proposals, and implement decisions. In large organizations, the effectiveness of managers depends on influence over superiors and peers as well as influence over subordinates (Yukl, 2006). In some aspects the terms leader and manager can be used interchangeably as a result of sharing a common goal which is to motivate people to act and to move forward. An exceptional leader is one who possesses an interpersonal quality with their followers and/or subordinates. When a leader lacks interpersonal skills, company morale tends to decline and employees begin to feel undervalued.

The structure of an organization is the focal point of an organization development. In-order for an organization to be successful it has to embrace the mission, vision and assessment. I believe these three components create the structure of an organization. For an organization to succeed, it has to develop a contemporary structure that embodies the mission, vision, and result due to rigorous assessment. Senge (1998) believed that a compelling vision is what inspires peoples passions, and that human beings have a purpose and reason for being, which is usually to make a positive difference.

The culture of an organization is the habitual principles which the leaders and followers align with to operate in an efficient manner and create a workable environment. In other word, the culture is the standard an organization perform its day to day activities. The followers are disciplined to abide by the rules and headed by their leaders. For example, if a company or business enterprise stipulates that their employees has to report to duty at 07:30 a.m. on each working days, and all must take 1 hour break within their working hours, I believe it is a fair argument that this is their culture and they certainly will not hesitate to follow the rule if they are aware and comfortable with it.

Impact of Stroke Case Study

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Introduction

Jithra is now 68 years of age. Her family consists of husband, daughter, nephew and nephew’s wife. She has been living with left side hemiplegia caused by stroke since she was 64. As this interview went, Jithra was holding her daughter’s hand and slowly elaborated her word by word experience in tears. Before an episode of stroke damaged the right side of her brain and put her in bed for the rest of her life, Jithra was living a life of a healthy person. She stated that poverty and debt were the most important factors that motivated her to wake up at 4:30 am on regular basis in order to prepare food and beverage for her respective customers who kindly supported her small restaurant. A strong belief that she did not have any health issue strengthened by the fact that an annual physical check-up was so expensive disguised Jithra from realising how essential it was to have her blood pressure and blood glucose level regularly monitored when she aged. As now that she spends her activities of daily living in bed, pressure sore has become the main concern for both Jithra and her family. Though Jithra does not complain of soreness, redness on skin does indicate that some areas need attention. This essay will provide an overview understanding of stroke and its negative effects posed on Jithra. Furthermore, this essay will emphasise on the intervention and prevention of pressure ulcer in depth.


Understand Stroke

According to World Health Organization (2014), stroke occurs when there is an interruption of the blood supply to a part of the brain. Stroke can be divided into two major types. The first type is called haemorrhagic stroke. This type of stroke accounts for approximately 13 percent of all strokes (Brown & Edward, 2012). It results from bleeding into the brain tissue. The bleeding caused by a rupture of blood vessels results in the leakage of blood into the brain impairing the delivery of oxygen and nutrients. Haemorrhagic stroke can be caused by a number of disorders affecting the blood vessels. Some of which are long-standing high blood pressure and cerebral aneurysms, a thin or weak spot on a blood vessel wall. The weak spots that cause aneurysms are usually present at birth. The development of aneurysms happens over a number of years and don’t usually cause detectable problems until they break (Stroke Foundation, 2014). Jithra’s daughter stated that Jithra complained of headache and nausea approximately 48 hours, especially during periods of activity, before an episode of stroke occurred. Headache particularly distinguishes haemorrhagic stroke from ischaemic stroke. Its other symptoms also include nausea, vomiting, decreased level of consciousness, neurological deficits and hypertension (Brown & Edward, 2012).

The second type is called ischaemic stroke. It accounts for approximately 85 percent of all strokes. According to Brown and Edward (2012), this type of stroke occurs as the result of partial or complete obstruction, caused by a blood clot, of a blood vessel that supplies blood to the brain. This leads to an insufficient of oxygen supply and glucose needed for cellular metabolism. A clot may be formed by means of embolism or thrombosis. Both types of clotting formations can be differentiated by their characteristics. The term embolism in relation to stroke is characterised by a condition where an embolus is created in one part of the brain or the body, circulates in the bloodstream, and eventually blocks the flow of blood through a vessel in another part of the brain (Crosta, 2009). This is called embolic stroke. On the other hand, the term thrombosis is characterised by the formation of a clot resulted from fatty deposits or plaque blocking the passage of blood through the artery. This type of clot remains in one area of blood vessels without being carried throughout the bloodstream. This is called thrombotic stroke (Brown & Edward, 2012).


Stroke risk factors

There are multiple risk factors associating with stroke as according with (Brown & Edward, 2012). The risk factors can be classified into non-modifiable risk factors and modifiable risk factors. Non-modifiable risk factors include age, gender, race and heredity. Modifiable risk factors include diabetes mellitus, heart disease, atrial fibrillation, heavy alcohol consumption, hypercoagulability, hyperlipidaemia, hypertension, obesity, physical inactivity, sickle cell disease and smoking.

Jithra, at 68, was diagnosed with hypertension or high blood pressure and diabetes mellitus. Age, hypertension and diabetes mellitus have played a key role in contribution to stroke. ‘Stroke risk increases with age, doubling each decade after age 55 (Brown & Edward, 2012, p. 1622).’ The rate of atherosclerotic development is usually increased by the stress of a constantly elevated blood pressure. The term atherosclerosis is referred to as hardening of the arteries resulting from the formation of fatty deposits or plaques. The narrowing of the blood vessels is its consequence. The carotid artery in the neck is a common site where these plaques develop and tend to break away and lodge in the vessels of the brain (Sander, 2013). Likewise, diabetes mellitus increases tendency towards the dysfunction of the inner linings of the blood vessel walls leading to an increase in the tendency towards the development of plaques. In addition, high cholesterol and triglyceride levels are highly likely among people with diabetes mellitus (Brown & Edward, 2012, p. 863).


Impact of Stroke

According to Brown and Edward (2012), stroke is a leading cause of serious, long-term disability. Jithra has been living with left side paralysis since she was 64 as a consequence of stroke. Immobility and the weakness in Jithra’s right arm and leg are the key limitations. She relies greatly on her family members when repositioning in bed is attempted and a combination of self-care abilities and activities of daily living, such as eating or drinking, are performed. Dysarthria, a disturbance in the muscular control of speech, is also experienced. Impairment may involve pronunciation, articulation and phonation. This helps explaining why Jithra feels uncomfortable communicating with strangers. As the interview went, a sudden change in emotion was spotted. Persons who have had a stroke may have difficulty controlling their emotions. Emotional responses may be exaggerated or unpredictable (Brown & Edward, 2012, p. 1628).The daughter said that Jithra sometimes cried without any reason. The interchanging between laughing and crying took only minutes to do so. Besides pressure, shearing force, friction and excessive moisture contribute to pressure ulcer formation (Maklebust & Sieggreen, 2001). As mentioned above that Jithra is bed-bound and greatly relies on her family members when repositioning is attempted, manual handling is used in order to lift and move her around the bed. However, the incorrect techniques combined with non-supportive equipment, such as sliding sheet, have put the maintenance of Jithra’s skin integrity becomes much more difficult.


Pressure Ulcer

According to Sydney South West (2008, p. 4), pressure ulcers are defined as “any lesion caused by unrelieved pressure when soft tissue is compressed between a bony prominence and an external surface for a prolonged period.” Factors that influence the development of pressure ulcers include the intensity of the pressure; the length of time the pressure is exerted on the skin; and the ability of the tissue to tolerate the externally applied pressure. Intrinsic factors that put Jithra at risk in developing pressure ulcers consist of advanced age, malnutrition and diabetes mellitus. Extrinsic factors include pressure, shear and moisture Sydney South West (2008).


Intervention

Although the skin remains intact, the appearance of persistent redness, particularly in sacrum, followed by itchy sensation indicates that stage one pressure ulcer has already developed. Stage one pressure ulcer can be intervened as referred to pressure ulcer intervention guidelines (Jones, 2013) by strictly maintaining the skin integrity. This can be done by relieving the externally applied pressure, protecting fragile skin and bony prominence, preventing friction and shearing and protecting skin from moisture.

In relieving the externally applied pressure, a regime of repositioning combined with the use of pressure relieving devices has already been utilised by Jithra’s daughter. However, it might not be enough in terms of the frequency. The frequency of repositioning depends on the ability of the tissue to tolerate the externally applied pressure. In this case, Jithra should move or be repositioned frequently enough in allowing reddened area of affected skin to recover from the effects of pressure. A turn clock may be a helpful reminder of correct body positions and appropriate turning times. Additionally, a 30-degree side lying position may well be utilised for Jithra as it diverts pressure from the sacrum. Maintaining a 30-degree side lying position can simply be done by using pillow or foam positioning wedges. However, lying on the side may increase pressure on extremities, especially knees and ankles. Placing pillows between the legs helps preventing opposing knees and ankles from exerting pressure on one another (Maklebust & Sieggreen, 2001).

In protecting fragile skin and bony prominence, an appropriate support surfaces shall be used and yet its cost has to be taken into consideration. Poverty and debt make it very difficult for Jithra to afford buying or renting them. ‘Charges can range from $24 to purchase a foam overlay to a daily rental fee of $125 for a highly technical therapy bed (Maklebust & Sieggreen, 2001, p. 75).’ Regardless of the variations in price, There is no scientific evidence that one support surface consistently works better than any others. Nevertheless, pressure points require protection whether at risk persons are in a bed or on a chair. Using pillows to bridge vulnerable areas, again simple, is an effective way to eliminate pressure. A regime of repositioning, together with the use of pillows has proved to be highly effective in protecting fragile skin and bony prominence.

In preventing Jithra from friction and shearing, a family education on how friction and shearing occur and correct usage of manual handling techniques and appropriate equipment shall be provided. Shear is greatest when a caregiver drags an at risk person along the surface of the sheets during repositioning or allows the person to slide from high-fowler’s position. In order to minimise shearing force, the head of the bed shall not be raised exceeding a 30 degree angle, unless the patient is eating. Furthermore, friction, a precursor of shear, is commonly caused by pulling a patient across the bed linen. Rubbing the protective layer of skin away increases the potential for deeper tissue damage.

Excessive moisture may be the result of sweating, wound drainage, soaking during bathing and faecal and urinary incontinence. Moist skin is five times as likely to become ulcerated as dry skin. The intervention guidelines suggested that protecting skin from moisture can be done by using continence management systems, using barrier skin cream to prevent skin maceration and keeping the site clean and dry. Living in a hot and humid country like Thailand may put Jithra at a higher risk of developing pressure ulcer due to sweating. Thailand normally has its temperature sitting at around 30 degree Celsius. Two fans, together with the application of baby powder are used in maintaining the dryness of Jithra’s skin.


Recommendation

According to Jones (2013), it is highly recommended that risk assessments must be done on Jithra by using the Waterlow scale. In doing so, her body mass index is required. The scale will give a score which helps identifying if Jithra is at risk, high risk or very high risk in developing pressure ulcers. Therefore, repositioning regime can be precisely arranged in order to ensure optimum pressure redistribution. Manual handling, together with the use of equipment such as hoists or slide sheets, effectively helps avoiding shear and friction. Education on the use of the mentioned equipment shall also be provided. A dietician shall be involved in discussing knowledge of healthy diet and considering the need for food fortification and nutritional supplements. Make sure that Jithra consumes adequate fibre and well hydrated as she is more prone to constipation due to immobility.


Conclusion

This can be concluded that the maintenance of skin integrity plays a key role in avoiding the development of pressure ulcers. Being rich or poor might not be the factors in treating and preventing pressure ulcers. This essay has shown how beneficial it is to have carers or family members who strictly put pressure ulcer intervention and prevention guidelines into practice to look after Jithra. The mattress that Jithra lays her body on might not be the best that the family can afford but frequently turning and maintaining dry skin have proved in lowering the risk of developing pressure ulcers. Only stage one pressure ulcer developed though, Jithra has been suffering from disability for 4 years.


References

Brown, D., & Edwards, H. (Eds.). (2012). Lewis’s medical-surgical nursing: assessment and management of clinical problems. NSW, Australia: Elsevier Australia.

Crosta, P. (2009). What Is Embolism? What Are The Different Types Of Embolism?.

Medical News Today.

Retrieved from

http://www.medicalnewstoday.com/articles/153704.php

Jones, D. (2013). Pressure ulcer prevention in the community setting.

Nursing Standard

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http://web.a.ebscohost.com.ezproxy.holmesglen.vic.edu.au/ehost/pdfviewer/pdfviewer?vid=3&sid=87c6951d-c6be-44c5-8985-c35d1918eb04%40sessionmgr4004&hid=4207

Maklebust, J., & Sieggreen, M. (2001). Pressure Ulcers: Guidelines for Prevention and Management (3rd ed.). Pennsylvania, USA: Springhouse Corporation.

O’Neill, P. A. (2002). Caring for the Older Adult: A Health Promotion Perspective. Pennsylvania, USA: W.B. Saunders Company.

Sander, R. (2013). Prevention and treatment of acute ischaemic stroke. Nursing Older People, 25(8), 34-39.

Scott, K., Webb, M., Sorrentino, S., & Gorek, B. (Eds.). (2006).

Long-term care assisting: Aged care and disability.

NSW, Australia: Elsevier Australia.

Stroke Foundation. (2014). Types of Stroke. Retrieve from

http://strokefoundation.com.au/what-is-a-stroke/types-of-stroke/

Sydney South West Area Health Service. (2007). Pressure Ulcer Prevention and Management. Retrieved from

http://www.sswahs.nsw.gov.au/pdf/policy/pd2008008.pdf

Watkins, C., & Leathley, M. (2010). Setting the scene. In Williams, J., Perry, L., & Watkins C. (Eds.), Acute Stroke Nursing (pp.1-16). Retrieved from

http://0-onlinelibrary.wiley.com.alpha2.latrobe.edu.au/store/10.1002/9781444318838.ch1/asset/ch1.pdf?v=1&t=ht43cw4l&s=1791526b00be208b196d718b1c2189904267ad40

World Health Organization. (2014). Stroke, Cerebrovascular Accident. Retrieved from

http://www.who.int/topics/cerebrovascular_accident/en/

Management of Sepsis

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Sepsis is defined as the overwhelming response of the human body and life-threatening reaction to a probable or documented infection which results in tissue hypoperfusion and organ dysfunction. Major sepsis had become recently common worldwide. 1 in 4 patients who presents with sepsis is likely to die of septic shock (Dombrovskiy, Martin, Sunderram, & Paz, 2007). The current diagnostic criteria for sepsis are hyperthermia of >38.3°C or hypothermia <36 °C, heart rate of >90 beats per minute, tachypnoea, altered mental status, hyperglycaemia, hypotension Systolic Blood Pressure of <90 mmHg, MAP of <70 mmHg, or a significant change of >40 mmHg in adults (Levy et al., 2003). Severe sepsis on the other hand reflects a massive amount of organ dysfunction such as decreased urine output of < 0.5 ml/kg/hour, poor creatinine clearance >34.2 μmol/L, Lactate levels above normal limits and persistent hypotension.

The current management of sepsis have been divided into initial resuscitation, screening, diagnosis, antibiotic therapy, source control and infection prevention. In managing sepsis, initial resuscitation will deal with physiological needs of patients especially whist in the Emergency Department, the goal is to load fluids to prevent hypotension and continue to monitor oxygen saturations ensure effective tissue perfusion is achieved. The second step is to screen patients as early identification of sepsis means early commencement of treatment that will reduce mortality rate (Levy M, 2010). Following screening for sepsis, a diagnosis needs to be performed. The best method to diagnose sepsis up to date is to collect blood cultures. Blood cultures is the most definitive way to confirm sepsis by identifying responsible pathogens (Weinstein, Reller, Murphy, & Lichtenstein, 1983). Ideally, two or more blood culture is the recommendation as of the current ACI guideline to have a better chance at identifying the causative pathogen. The commencement of treatment begins with the administration of antimicrobial therapy. The clinical excellence commission recommends administration of a broad-spectrum antibiotic within 1 hour of recognition of septic shock. Measurable increase in mortality had been associated to each hour antibiotics therapy has been delayed (Kumar et al., 2006). In the process of treatment, source control shall be empirical as the need to identify the source of the infection will more than likely prevent it from spreading further. An example of this is an infected vascular access device. Removal of an infected device shall stop further development of microbial contamination. In the case of an infected tissue such as necrosis or fasciitis, it is important that a debridement should be done immediately following successful resuscitation. Finally, the need for prevention of infection is equally as important as treating an infection. Some examples are simple hand washing, establishing a precaution when handling bodily fluids and promoting oral hygiene. These are some steps in managing sepsis in the emergency department and identifying them is quite challenging without a full and proper assessment of a patient.


Simulation based strategies:

According to a journal published in Yale University, simulation in healthcare is the most powerful way to facilitate learning and improve patient safety and best outcomes (Zigmont, Kappus, & Sudikoff, 2011). In blooms taxonomy, knowledge is the simplest form of learning, however the learning being able to analyse and synthesise knowledge to be applied is the best way of assessing competence. For instance, multiple choice questions can assess the learner’s competence about a certain topic, however it is limited to test the most basic of knowledge, it cannot test comprehension and analysis of the situation. In the bloom’s taxonomy triangle, when simulation-based learning is used to improve practice, it will allow the learner to put together knowledge and comprehension, apply the understanding towards practice, analyse and reflect from the learner’s point of view on the topic at hand and synthesise learning to change current practice and retain knowledge even longer. The blooms taxonomy’s important point is evaluation which is very crucial to formulating critical thinking. Critical thinking validates clinical studies by judging it’s relevance in patient application and effectiveness of intervention (Adams, 2015).


How simulation-based learning is used:

“In broad, simple terms a simulation is a person, device, or set of conditions which attempts to present evaluation problems authentically” (Issenberg, McGaghie, Petrusa, Lee Gordon, & Scalese, 2005). I strongly believe that high fidelity simulation learning is very important is important in the management of sepsis as it not only allows learners to treat and resuscitate patient presenting with sepsis, rather it would also help identify and recognise patients that are in early onset of sepsis before it is too late. Currently, there are sepsis simulation tools used in healthcare all over the United States of America and solely focused on medical professionals to resuscitate patients who present with severe sepsis. Most of the treatment outcomes recommended are aggressive and invasive including central venous pressure and arterial line blood pressure monitoring whilst in the intensive care unit. This may have already been caused by poor ward management or patients who have presented with sepsis but were not recognised earlier on the presentation. In the department I am currently working at, there is no proper training of how to detect sepsis apart from a simple screening tool provided by the agency for clinical innovation. This screening tool is hardly ever used and mostly fail to recognise and differentiate the patient’s presenting problems.

The simulation should aim to teach all healthcare professionals including but not limited to: physicians, registered and enrolled nurses, lab technicians, assistant in nursing, and pharmacist. Learning should be as realistic as possible and should identify gaps in participant education. The learning space should replicate the relevant care environment and where possible, should be performed in the emergency department. If a setting such as a patient’s room is not achievable, the supplies should be coordinated by the facilitator such that it will depict the actual reality of the availability of the equipment and supplies. The training should be conducted in a classroom setting and will need to discuss the concepts and basics of the sepsis pathology and illness process. This will decrease the instances where the learner will be looking at printed materials and go over the documents hence avoiding frustration and stress. Following the classroom learning, a simulation event should be conducted and scenarios should be ready for the group to react.

Simulation is a very interactive method of teaching and will ensure the participant understands all the concepts and the patient care required in a specific scenario. It will also determine each learners’ actions and rationalise their actions towards each scenario. At the end of the simulation, A debrief and with the facilitator should be conducted and should discuss issues that may arise in each particular scenario. Some examples of issues that may arise will include poor knowledge of the equipment use, poor communication and untimely administration of antibiotics etc.


Types of simulation technology to be used:

The simulated learning may be conducted in a realistic patient care environment such as a simulation lab in the hospital or a spare unused bedspace in the hospital or department. It may use either a mannequin which will be computer controlled or patient-actors that may be given a certain scenario to perform but will only respond to questions when they are asked. Being in a realistic environment, the learners will be treated a true to life environment and use the available equipment and respond with realistic timelines. Ideally each scenario will have supplies and equipment for the use of the learners. The use of mannequins can provide a better learner experience. It is empirical for learners to familiarise themselves with the setting and the availability of the equipment to use. This removes significant worries and reduces the amount of time that the learners will be looking at resources or looking for equipment to use during the scenario and may affect significantly the efficacy of the scenario. The learner should perform each assessment against a mannequin or a real patient actor and “interact” in order to master the skill of assessment and communication. The intention of simulated learning is to ensure the learning does not happen in a passive manner. Simulated learning is only able to create realism to a certain degree, the debriefing at the end of the learning scenario will reinforce realisation and take the learner back to the situation and focus on the action and create a state of reflection. The role of the simulation facilitator is very important in reinforcing knowledge and reflection to be used in clinical practice (Arafeh, Hansen, & Nichols, 2010). Video playback can also help with reflection. Apart from being entertaining, video playback can create perspective to the whole simulation scenario and a good help in going back to the learner actions during the scenario (Arafeh et al., 2010).




Research in simulation studies & evaluate effectiveness in terms of outcomes:

Simulation is a great way of measuring outcomes and identifying dearth in basic knowledge about sepsis and its management. Learners will be highly motivated and very involved in the simulation (Hoberman & Mailick, 1992). According to an article I have read, simulations should be designed (1) to provide instruction on the scenarios, (2) to provide opportunities to assess performance and provide “diagnostic feedback”. (3) a facilitated learning experience (4) the fidelity of the simulated learning is kept towards the task’s goals and objectives. It is then effective and efficient in managing individual performance assessment, promotes safety of patients and reduces human errors (Salas & Burke, 2002). Simulation based learning is the answer to bridge the gap between knowledge and application of concepts. It will measure technical, problem solving and decision-making skills of each participants and will challenge each personalities to work as a team in order to provide an effective and efficient quality patient care with the goal to minimise human errors in the decision making process (Lateef, 2010). The effectiveness of the simulation can be further assessed using a good debriefing technique. There are two types of debriefing techniques. (1) Technical Debrief, (2) Cognitive Debrief. Technical debrief tends to go back into evaluating performance of each team member and usually talk amongst each other and self-correct as a team. With the help of a facilitator, a reflection can identify areas of improvement and further learning opportunities. A cognitive debrief on the other hand is to identify errors and difficulties encountered during the scenarios and is usually reported using a questionnaire or tool to directly measure the participants or learners’ perceptions (Farnik & Pierzchała, 2012). Although there are very little resource and peer-reviewed journals about debriefing there are a few strategies in debriefing being developed and new methods of assessment. In a final note, debriefing is considered the “heart and soul” of the whole simulated learning approach. It is crucial that a well-defined learning objective is made a basis of each scenario and used as a guide to debrief participants. A very good debrief is considered the “ideal reinforcement of current practice.” (Arafeh et al., 2010)


References:

  • Adams, N. E. (2015). Bloom’s taxonomy of cognitive learning objectives.

    Journal of the Medical Library Association : JMLA, 103

    (3), 152-153. doi:10.3163/1536-5050.103.3.010
  • Arafeh, J. M. R., Hansen, S. S., & Nichols, A. (2010). Debriefing in Simulated-Based Learning: Facilitating a Reflective Discussion.

    The Journal of Perinatal & Neonatal Nursing, 24

    (4), 302-309. doi:10.1097/JPN.0b013e3181f6b5ec
  • Dombrovskiy, V. Y., Martin, A. A., Sunderram, J., & Paz, H. L. (2007). Rapid increase in hospitalization and mortality rates for severe sepsis in the United States: a trend analysis from 1993 to 2003.

    Crit Care Med, 35

    (5), 1244-1250. doi:10.1097/01.CCM.0000261890.41311.E9
  • Farnik, M., & Pierzchała, W. A. (2012). Instrument development and evaluation for patient-related outcomes assessments.

    Patient related outcome measures, 3

    , 1-7. doi:10.2147/PROM.S14405
  • Hoberman, S., & Mailick, S. (1992).

    Experiential management development: From learning to practice

    : Quorum Books.
  • Issenberg, S. B., McGaghie, W. C., Petrusa, E. R., Lee Gordon, D., & Scalese, R. J. (2005). Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review.

    Med Teach, 27

    (1), 10-28. doi:10.1080/01421590500046924
  • Kumar, A., Roberts, D., Wood, K. E., Light, B., Parrillo, J. E., Sharma, S., . . . Cheang, M. (2006). Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock.

    Crit Care Med, 34

    (6), 1589-1596. doi:10.1097/01.CCM.0000217961.75225.E9
  • Lateef, F. (2010). Simulation-based learning: Just like the real thing.

    Journal of emergencies, trauma, and shock, 3

    (4), 348-352. doi:10.4103/0974-2700.70743
  • Levy M, D. R., Townsend S,. (2010). The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis.
  • Levy, M. M., Fink, M. P., Marshall, J. C., Abraham, E., Angus, D., Cook, D., . . . International Sepsis Definitions, C. (2003). 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference.

    Intensive Care Med, 38

    , 367–374. doi:10.1007/s00134-003-1662-x
  • Salas, E., & Burke, C. S. (2002). Simulation for training is effective when.

    Qual Saf Health Care, 11

    (2), 119-120. doi:10.1136/qhc.11.2.119
  • Weinstein, M. P., Reller, L. B., Murphy, J. R., & Lichtenstein, K. A. (1983). The clinical significance of positive blood cultures: a comprehensive analysis of 500 episodes of bacteremia and fungemia in adults. I. Laboratory and epidemiologic observations.

    Rev Infect Dis, 5

    (1), 35-53. doi:10.1093/clinids/5.1.35
  • Zigmont, J. J., Kappus, L. J., & Sudikoff, S. N. (2011). Theoretical foundations of learning through simulation.

    Semin Perinatol, 35

    (2), 47-51. doi:10.1053/j.semperi.2011.01.002

Demonstrate an awareness of how current theories and government guidelines influence an individuals health and individual needs (gov websites) are they working?

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Demonstrate an awareness of how current theories and government guidelines influence an individuals health and individual needs (gov websites) are they working?

 

Order title:
Perspectives of Health

Instructions:
An explanation of what defines health
The principles of health
The concepts of health
The dimensions of health – physical, emotional, social and spiritual
Explain how health promotion models are used in practice
Demonstrate an awareness of how current theories and government guidelines influence an individuals health and individual needs (gov websites) are they working?
Outline the major current trends for health promotion and explain the link between these national trends and health
Explain how the health of an individual can be understood in relation to the influence of national trends (UK)
Research and explain conventional health care
Explain increasing demand for Complementary therapies within U.K. Healthcare
Explain the need for integrated health care by identifying individual contributions made in establishing and maintaining positive health
Evaluate the conclusions of data research in relation to the stated objectives above.Currently 1 writers are viewing this order

Combined Pulmonary Fibrosis and Emphysema (CPFE)

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Ong Wei Jun Dan


The Causes, Consequences and Differences Between Pulmonary Fibrosis or Emphysema Alone


Abstract

Combined pulmonary fibrosis and emphysema (CPFE) is a complicated disease and untreated disease which consists of two diseases. It is difficult for respiratory therapists or respiratory physicians to differentiate between CPFE versus idiopathic pulmonary fibrosis (IPF)/emphysema alone. There is an increased recognition of the coexistence of emphysema and pulmonary fibrosis in individuals. The association of two diseases results in chronic dyspnea, upper-lobe emphysema and lower lobe fibrosis, and severely diminished diffusion of gas exchange with preserved lung volumes. CPFE is also frequently complicated by pulmonary hypertension, lung injury and even lung cancer. This causes CPFE patients to feel have a low quality of life and a low 10-year survival rate. Currently, there are no known treatments for CPFE patients with the exception of lung transplantation. Thus, clinical evaluations are needed to differentiate between chronic obstructive pulmonary disease (COPD) and pulmonary fibrosis, and to recognize that CPFE is a unique entity by looking at the difference in radiological, pathological and metabolism features in order to find better treatment for CPFE.


Introduction

About 11 million Americans have Chronic Pulmonary Obstructive Disease (COPD) and out of these, most are diagnosed with pulmonary emphysema. The etiology of emphysema found that 80% of cases are caused by cigarette smoking, which causes alveolar membranes to break down, creating huge alveoli (called blebs) that lesser surface area and weaker walls than normal alveoli. This causes the low perfusion of oxygen due to decrease in surface area. In addition, approximately 50,000 new cases of Idiopathic Pulmonary Fibrosis (IPF) are diagnosed each year.  IPF is a restrictive respiratory disease, and it is the most common of the idiopathic lung diseases. IPF causes thickening of the alveolar capillary membrane, which results in minimal gas exchange between the alveolar and the blood capillaries. Both diseases lead to the decreased efficacy of oxygen delivery.

CPFE is a combination of both IPF and emphysema. However, it is usually treated as IPF and ignored or excluded in the diagnosis of emphysema.  COPD and pulmonary fibrosis have different pathologies, metabolic pathways and radiological characteristics, and were therefore regarded as separate entities for a very long time. However, in recent years, there is some recognition of the coexistence of pulmonary fibrosis and emphysema in patients. As such, it is very important to know the differences between CPFE versus emphysema or pulmonary fibrosis alone in order to find a treatment or prevent the patient’s conditions from further deteriorating.

In the following years, studies had shown that CPFE patients have a coincidental occurrence of early emphysema and at later age of IPF, especially for smokers with many pack years.

1

However, in recent studies there is a correlation between the occurrence of the combination between lower lobe pulmonary fibrosis and upper lobe emphysema. These two diseases have been observed coexisting in greater frequencies which are therefore called combined pulmonary fibrosis and emphysema (CPFE) and there is a need to distinguish them as distinct entities. There are some studies taking place to better understand the pathophysiology of the condition and find the possible causes of CPFE such as genetic factors or any biological metabolism pathways which may encourage its development. CPFE is normally caused by heavy smoking, exercise hypoxemia, upper lobe emphysema and lower lobe pulmonary fibrosis, unexpected lung volume and severe reduction of carbon monoxide transfer.

2

Whether the combination of both emphysema and pulmonary fibrosis is a unique clinical entity still remains unknown. For some of the population in the medical community, it is a coincidental occurrence of two smoking-related diseases on one person, versus the coexistence of the similarities of COPD and lung cancer. However, many different studies have shown and suggested that interstitial lung abnormalities, which are normally caused by IPF, have are inversely related to emphysema in smokers. In fact, based on the chest X-Ray images, most patients who have many pack years with IPF do not have any signs of having emphysema. Similarly, most patients who have emphysema do not have any signs of IPF in their chest X-Ray. Hence, the combination of both pulmonary fibrosis and emphysema may be a direct result of heavy smoking or many pack years which reflects the uniqueness in individual susceptibilities.

Even though medical professionals tend to use chest X-Rays for any respiratory distress, as it is inexpensive and considered a fast diagnostic tool, it is unable to properly diagnose the CPFE syndrome. Another alternative would be to use High-Resolution Chest Computed Tomography (HRCT), which is the only tool to diagnose the syndrome. The CPFE syndrome consists of heterogeneous syndromes, in which syndromes differ from one individual to another and resulting in no actual definition of the syndrome for CPFE. This makes it difficult to diagnose CPFE with the current pulmonary function test, as CPFE patient results look similar to those of patients diagnosed with pneumonia. From past research and observations, CPFE is frequently complicated with pulmonary hypertension, acute lung injury and the possibility of lung cancer, resulting in very poor prognoses. Treatments for CPFE patients with severe pulmonary hypertension have not been found and have largely proven ineffective in curing the disease apart from a wholesale lung transplant.

The identification of patients with CPFE is needed due to the uniqueness and complication of the disease’s history. Since CPFE has not yet attracted the attention of researchers and healthcare practitioners, there have not been many studies focused on finding the differences between pulmonary fibrosis, emphysema and CPFE. Currently, there is no consistent way to differentiate the factors, signs and syndromes when diagnosing CPFE patients from other obstructive respiratory diseases. This has resulted in many medical practitioners failing to immediately recognize CPFE in patient’s diagnoses.


Population distribution of Emphysema, IPF and CPFE

The prevalence of the disease emphysema was reported to be at about 24.5 per 1,000 in America, while the prevalence of IPF varied from 14 to 42.7 cases per 100,000. Therefore, emphysema is a more common disease as compared to IPF. However, there are no studies that account for the prevalence of CPFE. Some of the reported observations show that the proportion of patients with CPFE detected on HRCT scans range from 8% to 51% in IPF patients. On the other hand, the proportion of pulmonary fibrosis found in patients with emphysema is less than 10% using the HRCT. This variation of proportion of prevalence in CPFE may be due to the different types and complications arising from the diagnosis of emphysema when evaluated by chest X-Ray and HRCT.

Patients with CPFE tend to be older men who tend to have many pack years of smoking. Previous studies have shown that there is no significant difference when varying the number of pack years against the occurrence of COPD such as emphysema and CPFE. However, patients with CPFE and those with COPD usually have a long history of smoking as compared to patients with IPF.  Many studies have reported that male have higher prevalence then female in having respiratory disease syndrome, and could be due to men tending to have more pack years as compared to females. It may also be due to the genes of men which predispose them to succumbing to COPD or CPFE. Even though both IPF and emphysema have proven to be more common in male smokers than female smokers, it does not necessarily mean that gender plays an important risk factor in the contraction of CPFE. More studies are needed to determine how gender differences affect this syndrome.


Pathology pathway of CPFE

Till now, there are no conclusive findings for pathogenies of CPFE. There are no clear conclusions on the development of CPFE, whether emphysema and or pulmonary fibrosis progress independently or whether there are synergistic qualities between the two. There may be some mechanisms involving cytokines, beta receptors or signaling pathways which have not been discovered. Thus, both pulmonary fibrosis and emphysema may tend to occur in genetic susceptibility individuals with from exposure to environmental factors such as smoking or occupational hazard and chemicals.


Case Study of a CPFE patient (Occupational exposure)

A case study journal report on a male patient aged 73 years old in 2015 gives one of the more detailed analysis of Microscopic Polyangiitis (MPA), a disease that precedes by CPFE. The patient worked as a metalworker and had 25 pack years. He was admitted to the hospital due to progressive dry coughing and he was later diagnosed with CPFE. He eventually died due to complications from CPFE, which resulted in severe pneumococcal pneumonia with acute lung injury. His arterial blood gas result was normal with a fairly abnormal range in his pulmonary function test (PFT). There were clear signs of emphysema and IPF from his CT scan and Chest X-Ray (Kyoko Gocho, 2015). MPA is a systemic necrotizing vasculitis of small vessels associated with numerous types of antibodies in particular myeloperoxidase- antineutrophil cytoplasmic antibody (MPO-ANCA). Oxidation induced by MPO-ANCA may trigger pulmonary fibrosis due to alveolar hemorrhage, resulting in pulmonary capillaritis (an inflammation of pulmonary capillary). This causes pulmonary fibrosis as the alveolar capillary wall thickens (Kagiyama, 2015)


Correlation of smoking with CPFE patients

A common etiology factor for CPFE is smoking. Tobacco smoke contains 4000 chemical substances, including Kaolinite or aluminum silicate, an organic industrial material. Studies show that inhalation of this organic industrial substance will result in hyperactive macrophages, which in turn will lead to respiratory bronchiolitis and emphysema (King, 2005). Currently, there are no studies for the association of tobacco smoking resulting in IPF, other factors such as environmental factors in genetically-predisposition individuals may play a key role in resulting IPF. The association between CPFE and lung cancer may reflect the susceptibility linked to long term smoking which causes chronic smoking-induced inflammation. These were done on several other studies on the relationship between emphysemaand IPF.

3,4


Pathological findings (Diagnostic Imaging)

Patients who have acute respiratory distress syndrome such as COPD, pulmonary fibrosis or even CPFE, will tend to have more difficulty breathing due to the use of accessory muscles and the need to constantly supply supplemental oxygen to meet the oxygen level demanded by the body. For some of the patients, a high flow of oxygen is required (flow rate of more than 60L/min) to meet their inspiratory demand. Patients with CPFE have a confused and undetermined ventilation/ perfusion ratio due to emphysema causing low perfusion and IPF having low ventilation. This results in both ventilation of oxygen to the alveoli and perfusion of capillaries to be diminished, leading to dead space and shunt. Emphysema results in the reduction of alveoli-capillary surface membrane by forming a bleb that causes air-trapping, whereas pulmonary fibrosis scars the alveoli’s tissue, creating a shunt that causes ventilation of the oxygen to the alveoli to be inefficient, resulting in the patient’s body tissue being unable to get a sufficient amount of oxygen.

Other remarkable syndromes found in COPD patients are chronic cough and sputum production in volume greater than one shot full glass due to inflammation of bronchi and impairment of the mucociliary clearance, presumably due to the effects of smoking. Patients with IPF may show progressive shortness of breath, loud expiratory wheezing sounds and – if the condition is worse – cyanosis may appear on the patient. CPFE from previous clinical studies shows that it is similar to IPF. On close physical examination, by doing chest auscultation, it was found that more than 80% of CPFE patients will emit inspiratory dry crackles sounds due to the underlying pulmonary fibrosis. About 40 to 50% will have digit clubbing and poor capillary refill.



As of now, there is no consistent definition for CPFE. However, it is very important to diagnose it early. Diagnostic criteria for CPFE include radiological findings by using either chest X-Ray or HRCT – these images will appear as upper-lobe emphysema with fibrosis like blebs, lower-lobe honeycombing with subpleural reticular opacities, thick wall cystic lesions, and sometimes ground glass opacities.

2

Table 1: Comparison of clinical characteristics difference between CPFE, emphysema and IPF patients’ group (measures of Framingham variables)
CPFE IPF Emphysema p-value
Sample size 22 8 17

Age (in years)
Median 73.5 74 78 0.7
Range 59-96 56-89 48-86

Number of pack years
Median 64 43 75 0.64
Range 20-50 30-80 15-65
Table 2: Comparison of clinical characteristics difference between CPFE, emphysema and IPF patients’ group (Pulmonary Function Test)
CPFE IPF Emphysema p-value
Vital capacity 2.52±0.72 2.34±0.86 2.85±0.61 0.52
Vital capcity (%) 83.1±22.1 68.0±27.7 87.0±12.4 0.29
FEV

1
 2.01±0.19 1.60±0.24 1.57±0.22 0.28
FEV

1

/FVC(%)		 76.8±3.31 81.8±4.45 55.6±4.06 <0.01
DLCO 6.30±3.89 9.68±3.65 15.45±6.34 0.02
DLCO (%) 36.6±17.5 57.1±27.4 102.5±58.1 0.02
Table 3: Comparison of clinical characteristics difference between CPFE, emphysema and IPF patients’ group (Treatment)
CPFE IPF Emphysema p-value
Inhaled Corticosteriods (ICS) 14 (63.6%) 6 (75%) 0.45
Immunosuppresive agent 3 (13.7%) 1 (12.5%) 0.73
Long-term oxygen therapy 5 (22.7%) 1 (12.5%) 17 (100%) 0.48
Table 4: Comparison of clinical characteristics difference between CPFE, emphysema and IPF patients’ group (Cause of death)
CPFE IPF Emphysema p-value
Lung cancer 9 (40.9%) 1 (12.5%) 13 (83.1%) 0.007
Acute infection or inflammation exacrbation 6 (27.2%) 5 (62.5%) 0.09
Infection 4 (18.1%) 1 (12.5%) 1 (6.3%) 0.52
Myocardial infarction 2 (9.1%) 0 (0%) 1 (6.3%) 0.61
Others 1 (4.5%) 1 (12.5%) 1 (6.3%) 0.73

CPFE unfortunately is regarded as a unique entity and till now, it is rarely recognized as a clinical entity. Based on the GOLD standard for COPD patients, to be diagnosed for COPD, FEV

1

/FVC should be less than 70%. However, in CPFE patients, they normally have subnormal lung volumes and pulmonary function test with FEV

1

/FVC > 70%, this results being emphysema to be ignored or overlooked. Physician, healthcare workers and respiratory therapists should be aware of its existence. More autopsies should be recognized such as thick-walled cystic lesion and idiopathic interstitial pneumonia should be recognized as both of these can be found in CPFE patients but are seldom found in emphysema/IPF alone patients. A deeper understanding of the pathophysiology is needed for CPFE and the factors that causes the syndrome of CPFE should be explored further with more clinical studies so as to develop effective treatments or therapeutic strategies for CPFE patients.


References

  1. Hiwatari H., S. S. (1993). Pulmonary emphysema followed by pulmonary fibrosis of undetermined cause.

    Respiration

    , 60(6).
  2. Cottin V., H. N. (2005). Combined pulmonary fibrosis and emphysema: a distinct underrecognised entity.

    European Respiratory Journal

    , 26(4).
  3. Kaplan R. M. (2015). Quality of Well-being Outcomes in the National Emphysema Treatment Trial.

    Chest Journal

    , 147(2).
  4. Kagiyama C., N. T. (2015). Antineutrophil cytoplasmic antibody-positive conversion and microscopic polyangiitis development in patients with idiopathic pulmonary fibrosis.

    BMJ Open Respiratory Research

    , 2(1).
  5. Inomata M., A. M. (2013). An autopsy study of combined pulmonary fibrosis and emphysema: correlations among clinical, radiological, and pathological features.

    BMC Pulmonary Medicine,

    104(14).
  6. King, C. G. (2005). COPD: a dust-induced disease?

    Chest Journal

    , 128(4).
  7. Kyoko G. (2015). Microscopic polyangiitis preceded by combined pulmonary fibrosis and emphysema.

    Respiratory Medicine Case Reports

    , 10(2).
  8. Papaioannou A. I., E. A. (2016). Combined pulmonary fibrosis and emphysema: The many aspects of a cohabitation contract.

    Respiratory Medicine, 117

    (10).

9.   Portill K., J. M. (2011). Combined Pulmonary Fibrosis and Emphysema Syndrome: A New Phenotype within the Spectrum of Smoking-Related Interstitial Lung Disease.

Pulmonary Medicine

, 2012(1).

Why do you do service? For self-interest or altruism?

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Why do you do service? For self-interest or altruism?

Order Description

• How did this experience challenge your assumptions and stereotypes?
• Why do you do service? For self-interest or altruism?
• Describe how teamwork and collaboration played a part in providing a service for the community?
• How does evidenced-based practice relate to community health.
• Describe the importance of health promotion and health teaching in the community setting.
Course Objective: The following course objectives will be fulfilled by participating in this service learning project:
• Identify methods of personal responsibility and accountability in the nursing profession (Professional Idenity).
• Communicate effectively with students, faculty, patients, and staff in all aspects of course learning activities and assignments (Teamwork and Collaboration).
• Explain the concepts of evidenced-based practice, in managing the care of one patient with a commonly occurring alteration in health, in collaboration with the healthcare team (Evidenced-Based Practice).
• Develop a basic teaching plan for an assigned patient using appropriate teaching methods. (Health Teaching & Health Promotion)

Reflections

1. Introduction
2. Select reflection questions to adequately address the service learning project.

3. Personal reflection:
• Describe the importance of this project.
• What did you learn during this service learning project?

4. What is your civic responsibility to the community?

5. How did participation in this event play a role in developing your professional identity?

SLO: Professional Identity

40 points